Hahr and Molitch Clinical Diabetes and Endocrinology (2015) 1:2 DOI 10.1186/s40842-015-0001-9
REVIEW ARTICLE
Open Access
Management of diabetes mellitus in patients with chronic kidney disease Allison J. Hahr and Mark E. Molitch*
Abstract Glycemic control is essential to delay or prevent the onset of diabetic kidney disease. There are a number of glucose-lowering medications available but only a fraction of them can be used safely in chronic kidney disease and many of them need an adjustment in dosing. The ideal target hemoglobin A1c is approximately 7 % but this target is adjusted based on the needs of the patient. Diabetes control should be optimized for each individual patient, with measures to reduce diabetes-related complications and minimize adverse events. Overall care of diabetes necessitates attention to multiple aspects, including reducing the risk of cardiovascular disease, and often, multidisciplinary care is needed. Keywords: Diabetes, Chronic kidney disease, Diabetic kidney disease, Nephropathy, Glycemic control, Hemoglobin A1c
Introduction Diabetes mellitus is a growing epidemic and is the most common cause of chronic kidney disease (CKD) and kidney failure. Diabetic nephropathy affects approximately 20–40 % of individuals who have diabetes [1], making it one of the most common complications related to diabetes. Screening for diabetic nephropathy along with early intervention is fundamental to delaying its progression in conjunction with providing proper glycemic control. Given the growing population that is now affected by diabetes and thus, nephropathy, knowledge regarding the safe use of various anti-hyperglycemic agents in those with nephropathy is of importance. In addition, attention to modification of cardiovascular disease (CVD) risk factors is essential. Altogether, knowledge regarding the prevention and management of diabetic nephropathy, along with other aspects of diabetes care, is part of the comprehensive care of any patient with diabetes. Review Recommendations for nephropathy screening in diabetes
Patients with diabetes should be screened on an annual basis for nephropathy. In individuals with type 1 diabetes, screening for nephropathy should start 5 years after * Correspondence: [email protected] Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Avenue, Suite 530, 60611 Chicago, Illinois, USA
diagnosis of diabetes since the onset of diabetes itself is usually known. It typically takes about 5 years for microvascular complications to develop. In patients with type 2 diabetes, screening should begin at initial diagnosis since the exact onset of diabetes is often unknown [1]. Diabetic nephropathy can be detected by the measurement of urine albumin or serum creatinine, and both tests should be performed at minimum annually [1]; those with abnormal levels should have repeat tests done sooner. The first stage of nephropathy is usually the onset of elevated urine albumin which predicts the development of CKD and a gradual decline in glomerular filtration rate (GFR). Some individuals with CKD, however, do not develop elevated urine albumin initially. It is therefore important that individuals have both blood and urine screening tests performed. Using both modalities allows for identification of more cases of nephropathy than using either test alone. The urine albumin to creatinine ratio can be measured on a spot or timed urine collection such as 4 or 24 h. Microalbuminuria is defined as >30 mg/g creatinine or 30 mg per 24 h. Clinical-or macro-albuminuria is defined as >300 mg/g creatinine or 300 mg per 24 h. An abnormal value should be confirmed on at least one additional urine specimen over a 6 month period. Recently, the terms “moderately increased” and “severely increased” albuminuria have been introduced to replace the terms “microalbuminuria” and “macroalbuminuria”.
© 2015 Hahr and Molitch; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Hahr and Molitch Clinical Diabetes and Endocrinology (2015) 1:2
Increased albumin excretion is not only a marker for early diabetic kidney disease but also for increased risk for macrovascular disease [1]. Other causes of elevated urine protein should be considered and avoided such as infection, strenuous exercise, hypertension, heart failure and hematuria. The serum creatinine should be used to estimate GFR and thus, the level of CKD. One must also consider that the development of nephropathy may not be related to the diabetes itself. In patients with type 1 diabetes, the onset of retinopathy usually precedes the development of nephropathy. An individual who present with nephropathy but no retinopathy should have an evaluation for other causes. Referral to a nephrologist should be utilized to establish the cause of nephropathy when this is uncertain. Nephrologists are also vital to assist management of complications of advancing kidney disease, such as difficult to control hypertension, hyperkalemia and rapid progression [1, 2]. Glycemic control in CKD
Glycemic control is essential to delay the onset of complications from diabetes, and it can be challenging for even the most experienced physician. Blood sugar control in those with CKD adds another level of complexity. It requires detailed knowledge of which medications can be safely used and how kidney disease affects metabolism of these medications. In addition, the glycemic target needs to be individualized for each patient, acknowledging that our ability to interpret the data can be altered in the setting of kidney disease. Glycemic goal to attain A1c ~7.0 %
Glycemic control is essential to delay or possibly prevent nephropathy. In general, the recommended target A1c for diabetes control by the ADA has been less than or around 7 % [3]. The ADA advises both higher (
REVIEW ARTICLE
Open Access
Management of diabetes mellitus in patients with chronic kidney disease Allison J. Hahr and Mark E. Molitch*
Abstract Glycemic control is essential to delay or prevent the onset of diabetic kidney disease. There are a number of glucose-lowering medications available but only a fraction of them can be used safely in chronic kidney disease and many of them need an adjustment in dosing. The ideal target hemoglobin A1c is approximately 7 % but this target is adjusted based on the needs of the patient. Diabetes control should be optimized for each individual patient, with measures to reduce diabetes-related complications and minimize adverse events. Overall care of diabetes necessitates attention to multiple aspects, including reducing the risk of cardiovascular disease, and often, multidisciplinary care is needed. Keywords: Diabetes, Chronic kidney disease, Diabetic kidney disease, Nephropathy, Glycemic control, Hemoglobin A1c
Introduction Diabetes mellitus is a growing epidemic and is the most common cause of chronic kidney disease (CKD) and kidney failure. Diabetic nephropathy affects approximately 20–40 % of individuals who have diabetes [1], making it one of the most common complications related to diabetes. Screening for diabetic nephropathy along with early intervention is fundamental to delaying its progression in conjunction with providing proper glycemic control. Given the growing population that is now affected by diabetes and thus, nephropathy, knowledge regarding the safe use of various anti-hyperglycemic agents in those with nephropathy is of importance. In addition, attention to modification of cardiovascular disease (CVD) risk factors is essential. Altogether, knowledge regarding the prevention and management of diabetic nephropathy, along with other aspects of diabetes care, is part of the comprehensive care of any patient with diabetes. Review Recommendations for nephropathy screening in diabetes
Patients with diabetes should be screened on an annual basis for nephropathy. In individuals with type 1 diabetes, screening for nephropathy should start 5 years after * Correspondence: [email protected] Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Avenue, Suite 530, 60611 Chicago, Illinois, USA
diagnosis of diabetes since the onset of diabetes itself is usually known. It typically takes about 5 years for microvascular complications to develop. In patients with type 2 diabetes, screening should begin at initial diagnosis since the exact onset of diabetes is often unknown [1]. Diabetic nephropathy can be detected by the measurement of urine albumin or serum creatinine, and both tests should be performed at minimum annually [1]; those with abnormal levels should have repeat tests done sooner. The first stage of nephropathy is usually the onset of elevated urine albumin which predicts the development of CKD and a gradual decline in glomerular filtration rate (GFR). Some individuals with CKD, however, do not develop elevated urine albumin initially. It is therefore important that individuals have both blood and urine screening tests performed. Using both modalities allows for identification of more cases of nephropathy than using either test alone. The urine albumin to creatinine ratio can be measured on a spot or timed urine collection such as 4 or 24 h. Microalbuminuria is defined as >30 mg/g creatinine or 30 mg per 24 h. Clinical-or macro-albuminuria is defined as >300 mg/g creatinine or 300 mg per 24 h. An abnormal value should be confirmed on at least one additional urine specimen over a 6 month period. Recently, the terms “moderately increased” and “severely increased” albuminuria have been introduced to replace the terms “microalbuminuria” and “macroalbuminuria”.
© 2015 Hahr and Molitch; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Hahr and Molitch Clinical Diabetes and Endocrinology (2015) 1:2
Increased albumin excretion is not only a marker for early diabetic kidney disease but also for increased risk for macrovascular disease [1]. Other causes of elevated urine protein should be considered and avoided such as infection, strenuous exercise, hypertension, heart failure and hematuria. The serum creatinine should be used to estimate GFR and thus, the level of CKD. One must also consider that the development of nephropathy may not be related to the diabetes itself. In patients with type 1 diabetes, the onset of retinopathy usually precedes the development of nephropathy. An individual who present with nephropathy but no retinopathy should have an evaluation for other causes. Referral to a nephrologist should be utilized to establish the cause of nephropathy when this is uncertain. Nephrologists are also vital to assist management of complications of advancing kidney disease, such as difficult to control hypertension, hyperkalemia and rapid progression [1, 2]. Glycemic control in CKD
Glycemic control is essential to delay the onset of complications from diabetes, and it can be challenging for even the most experienced physician. Blood sugar control in those with CKD adds another level of complexity. It requires detailed knowledge of which medications can be safely used and how kidney disease affects metabolism of these medications. In addition, the glycemic target needs to be individualized for each patient, acknowledging that our ability to interpret the data can be altered in the setting of kidney disease. Glycemic goal to attain A1c ~7.0 %
Glycemic control is essential to delay or possibly prevent nephropathy. In general, the recommended target A1c for diabetes control by the ADA has been less than or around 7 % [3]. The ADA advises both higher (
